Reconsideration Request Form

If you are interested in filing an appeal of a denial of services or medications, please complete the applicable form below or have your physician complete the form.

For appeals related to clinical matters, please complete the Reconsideration Form and mail to:
Senior Whole Health
Quality Department
58 Charles Street
Cambridge, MA 02141

Download the Medicare Reconsideration Request Form (PDF). 

For appeals related to medications, please complete the online Redetermination Form:

Download the Request for Redetermination of Medicare Prescription Drug Denial (PDF).

Online Request for Redetermination.

Online Request for Prescription Drug Coverage Determination.


Last Updated 01/12/2018
H8851_2015_099 Approved 12/18/2014